MEDITERRANEAN SOCIETY of OTOLOGY AND AUDIOLOGY

Proposal for Membership

1. Name: Wife Name:

2. Business Address:

Business Telephone: Business Fax:

Email Address ( If you dont have any email address,please enter only default@politzersociety.org) :

Home Address:

Home Telephone:

3. Date and Place of Birth:

4. Education: Name of School Dates attended: Degree & Date

5. Otolaryngological training - Dates

6. College teaching appointments - Dates

7. Membership in Medical Societies:

8. Practice limited to Otology: Yes No

9. Length of Otolaryngology Practice:

10. Date of Submission:

Note: Annual membership fee is 50 Euros including the subscription of the Mediterranean Journal of Otology.

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Home Page - Bylaws - Executive Committee - Links - Otology Related Meetings

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